CITY OF ADRIAN POLICE DEPARTMENT
APPLICATION FOR EMPLOYMENT
NAME
Please print & fill out completely, leaving no blanks
Last First Middle
Other Names you have been known by:
ADDRESS
Number Street City State Zip
TELEPHONE NUM BER WHERE YOU MAY BE CONT ACTED
Day
( )
Evening
( )
DATE OF BIRT H*
Month Day Year
SOCIAL SECURIT Y NUMBER*
*For identification purposes only
DRIVER'S LICENSE NUM BER
STATE
HAVE YOU EVER BEEN ARREST ED? [ ] YES [ ] NO IF Y ES, EXPLAIN:
LIST ALL TRAFFIC OFFENSES/CRASHES W ITHIN PAST FIVE (5) YEARS:
MINIMUM 40 HOURS COLLEGE CREDIT : [ ] YES [ ] NO
ARE YOU C.O.L.E.S. CERT IFIED/CERT IFIABLE? [ ] YES [ ] NO
If Yes, give date of graduation and location of Academy attended:
If Yes, Date of Expiration of Current testing Certificate(s):
I hereby certify that all information cont ained in t his applicat ion is true to the best of my knowledge
and I underst and that any mis-information will subject me to disqualif ication and/or dismissal.
Signature Date
HAVE YOU COMPLETED C.O .L.E.S. PRE- EMPLOYMENT TESTING IN READING & WRITING AND PHYSICAL SKILLS? [ ] YES [ ] NO
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